Urinary Catheter Care Skills & Asepsis

Dr.T.V.Rao MD

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Urinary Catheter
Dr. Frederick Foley
Developed in the 1920s by Dr. Frederick Foley The urinary catheter was originally an open system with the urethral tube draining into an open container. In the 1950s, a closed system was developed in which the urine flowed through a catheter into a closed bag.
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What is a Foley's catheter

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What is a urinary catheter

Urinary catheter is any tube placed in the body to drain and collect urine from the bladder
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Catheter type

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Structure of Foley Catheter

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Urinary Catheter Utilization

About 15-25% of patients during their hospitalization will have an urinary catheter placed
Many are placed either in the intensive care or Emergency Department 40% - 50% of these patients do not have a valid indication for urinary catheter placement
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Purpose of Catheterization
Catheterization is carried out for a number of reasons and can either be a temporary or permanent solution to a number of problems. Problems include physical disease and damage, psychological issues and a way to help to improve the quality of life to someone who is bed ridden. Good regular catheter care involves good hygiene, observation, monitoring wellbeing and prevention of problems associated with catheterization.
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Foley Catheter

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Documentation
Details regarding the catheterisation should be recorded in the patients notes. For further information please refer to your hospitals policy and procedure manual.
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Matters to consider for Catheterization

Indication for catheterisation
Time and date of catheterisation Type of catheter Amount of water in balloon Size of catheter Expiry date of product Any problems on insertion Description of urine, colour and volume drained Specimen collected Review date (Marsden Manual 2001)
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What you Need for Catheterization

1 Dressing trolley 2. Catheterisation pack 3. Sterile gloves 4. Appropriate size catheter 5. Xylocaine jelly syringe 6. Sterile water for the balloon 7. Syringe 8. Specimen jar 9. Antiseptic solution 10. Waterproof Sheet 11. Extra Jug 12. Light source 13. Tape to secure the catheter to the leg 14. Drainage bag 15 Urine bag holder

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Choose the Right Catheter

Choose the smallest catheter size that will drain adequately for its intended use Catheters range in size from 5 24 Fg. (Joanna Briggs Institute 2003)
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Guidelines on Size
Women 12 14 Fg Men 16 18Fg Suprapubic 16 20Fg Haematuria 20 -24 Fg If a haematuria catheter is required a 3 way should be used to allow for the option of continuous bladder irrigation without requiring a further catheter change. When not in use, the irrigating port should be spigotted.
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Length of Catheters
Catheters are available in 3 lengths: Paediatric, Regular length and Female length. Female length is a shorter length catheter (2025cm). A shorter length catheter may be more convenient for ambulant women with a long term catheter. A shorter length catheter is not appropriate for all women particularly those who are bedridden or obese.
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Catheters in Obese Women

In obese women, the inflation valve of the shorter catheter may cause soreness by rubbing against the inside of the thighs, and the catheter is more likely to pull on the bladder neck (Britton &
Wright 1990; Pomfret 1996)
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Catheterization is a skill in Medicine

The ability to insert a urinary catheter is an essential skill in medicine. Catheters are sized in units called French, where one French equals 1/3 of 1 mm. Catheters vary from 12 (small) FR to 48 (large) FR (3-16mm) in size.
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Catheters are available in different varieties

They also come in different varieties including ones without a bladder balloon, and ones with different sized balloons - you should check how much the balloon is made to hold when inflating the balloon with water!
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What is indwelling Catheter

In indwelling urinary catheter is one that is left in place in the bladder. Indwelling catheters may be needed for only a short time, or for a long time. These catheters attach to a drainage bag to collect urine. A newer type of catheter has a valve that can be opened to allow urine to flow out, when needed. An indwelling catheter may be inserted into the bladder in two ways: Sometimes, one may insert a tube, called a suprapubic catheter, into your bladder from a small hole in your belly. This is done as an outpatient surgery or office procedure. 20-05-2013 Rao,s Infection care on FACEBOOK 19

Caution on catheterization
The potential for contact with a patient's blood/body fluids while starting a catheter is present and increases with the inexperience of the operator. Gloves must be worn while starting the Foley, not only to protect the user, but also to prevent infection in the patient. Trauma protocol calls for all team members to wear gloves, face and eye protection and gowns.

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Explain the patient before doing the catheritization

Before you start tell the person what you are going to do and why. This is important for everyone, but especially if the person is confused, has memory problems as in Alzheimer's disease or dementia. If you can, assist the catheterized person with their hygiene, rather than doing it yourself. It is important to try to help the person / patient keep their skills rather than just take over for them. There are so many advantages but it can just take that bit longer.
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Which Disinfectant Should be Used for Catheter Site Care?

Povidone-iodine (PI) is currently the most widely used agent for site disinfection
Chlorhexidine gluconate (CHG) has been compared to PI with mixed results We performed a formal meta-analysis of published and unpublished studies to clarify relative efficacy
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Skills in catheterization to be Perfected

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CONDOM CATHETERS
Condom catheters are most frequently used in elderly men with dementia. There is no tube placed inside the penis. Instead, a condomlike device is placed over the penis. A tube leads from this device to a drainage bag. The condom catheter must be changed every day.

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When Men suffer with Incontinence

When a man is unable to control his urine for long periods of time he is said to be incontinent. To avoid soiling his clothes and bed a condom-style sheath can be used to connect the penis to a closed drainage system in which the urine is collected. This avoids having a catheter inserted into the man's urinary bladder and greatly decreases the risk of bladder infections.

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INTERMITTENT (SHORT-TERM) CATHETERS

Some people only need to use a catheter on occasion. Short-term, or intermittent, catheters are removed after the flow of urine has stopped. For more information on this type of catheter, see: Clean intermittent selfcatheterization.
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Hand washing the most important preparation before catheterization

Wash your hands before and after handling the drainage device. Do not allow the outlet valve to touch anything. If the outlet becomes obviously dirty, clean it with soap and water.

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Antiseptic Hand Rinses many using alcohols

60-70% alcohol solutions Effective against most bacteria, viruses, fungi Protective against hand drying Faster, increased compliance
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Caring before the insertion of Catheter

Wash around the catheter entry site with soap and water twice each day. Clean the top several inches of the catheter too. Always wash the site after a bowel movement.

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Health care workers should develop skills in introduction of Catheter

Introduction Female urethral catheterization, the insertion of a catheter through the urethra into the urinary bladder to permit drainage of urine, is a fundamental skill Insert the catheter completely into the urethra, and do not inflate the balloon until there is return of urine, to avoid trauma
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Principles of placement of catheter and collecting bag

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The Urine collecting bag should be at a lower level to the patient to prevent retrograde flow

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 Criteria for insertion and continuation of a F/C includes:

a. Retention
b. c. d. e. f. g. h. i. j. Critical I&O Comatose Paralyzed Neurogenic Bladder Pre-op placement Wound with incontinence Bladder Irrigation Physical trauma/pain with bedpan/incontinence brief Terminal illness/comfort measures

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Care of Inserted Catheters

Every day , wash around the catheter and perineum with soap and water; rinse and dry these areas well. you may shower while wearing the catheter Sitting in the tub, however , is not recommended. Good personal hygiene pre vents the accumulation of bacteria, reduces the risk of infection, and prevents odor
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POSSIBLE COMPLICATIONS
Inability to catheterise
Urethral Injury by inflating balloon before insuring correct catheter placement in the bladder Infection Psychological Trauma Haemorrhage trauma sustained during insertion or balloon inflation False Passage by injury to the urethral wall during insertion Urethral Strictures following damage to the urethra long term problem Paraphimosis due to failure to return foreskin to normal position following catheter insertion.

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Complications of catheterization
The main complications are tissue trauma and infection. After 48 hours of catheterization, most catheters are colonized with bacteria, thus leading to possible Bacteriuria and its complications. Catheters can also cause renal inflammation, nephro-cysto-lithiasis, and pyelonephritis if left in for prolonged periods. The most common short term complications are inability to insert catheter, and causation of tissue trauma during the insertion. The alternatives to urethral catheterization include suprapubic catheterization and external condom catheters for longer durations.
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Urinary Catheter-related Infection: Background

Urinary tract infection (UTI) causes over 40% of hospital-acquired infections Most infections due to urinary catheters

25% of inpatients are catheterized

Leads to increased morbidity and costs
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Risks / Consequences of Catheterization

UTI
PYELONEPHRITIS DEATH R/T BACTEREMIA DAMAGE TO URETHRA (SCARRING AND STRICTURES) Prostatitis and epididymitis

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 Indwelling Foley catheters are a major source of UTIS.

Direct relationship between duration a f/c is in the patient and incidence of infection. Risk factors: Female Advanced age Duration Diabetes Renal insufficiency
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Biofilm: Extracellular Polymers

(Donlan, CID 2001; 33:138792, Liedl, Curr Opinion Urol 2001;11: 75-9)

Organisms attach to and grow on a surface and produce extracellular polymers Intraluminal ascent (48hours) of bacteria faster than extraluminal (72-168 hours) Most catheters used >1 week have biofilms Extraluminal more important in women
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Staphylococcus aureus biofilm on an indwelling catheter.

CDC Public Health Image Library

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What we are doing now, is it right things to do. Foley Catheter Bundle
What is the Foley Catheter Bundle?
Insert using sterile technique Hand hygiene before and after any contact with the F/C system Secure catheter to thigh at ALL times

Keep catheter bag below the level of the bladder at ALL times
Maintain a sterile, continuously closed system Specified criteria for insertion and continuation of a Foley catheter Peri care daily and after all incontinent stool What is Peri Care for a patient with a f/c? Daily wash with 20-05-2013 Rao,s Infection care on FACEBOOK warm soap & water then dry.

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Gravity will help the Draining of Bladder

Gravity is important for drainage and the prevention of urine backflow. Ensure that catheter bags are always draining downwards, do not become kinked and are secured and below thigh level. Metal or plastic hangers should be attached to the side of the bed. Cloth bags tied to the bed to support the bags are also available
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Collection of urine from catheterised patients

The process of obtaining a sample of urine from a patient with an indwelling urinary catheter must be obtained from a sampling port. The sample must be obtained using an aseptic technique. This port is usually situated in the drainage tubing, proximal to the collection bag which ensures the freshest sample possible. The use of drainage systems without a sampling port should be avoided (Gilbert, 2006).
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COLLECTION OF CATHETER SPECIMENS

In Urinary Tract Infections

Clean entry port with alcohol swab using firm friction and allow to air dry Insert syringe into direct entry point of bag and aspirate urine. The port will self-seal when the syringe is withdrawn. If direct syringe entry port is not available, insert needle into entry port and aspirate urine. The port will self-seal when the needle is withdrawn
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Specimens for Culturing Should not be Cultured from Urine bags

Specimens should not be collected from the tap from the main collecting chamber of the catheter bag as colonisation and multiplication of bacteria within the stagnant urine or around the drainage tap may have occurred.
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Aspirating the urine with syringe and Needle

Aspirating urine from a sampling port has traditionally been performed using a syringe and needle. However, needle-free systems are commercially available, which may reduce the risk of inoculation injury.
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Contraindications for catheterization

Foley catheters are contraindicated in the presence of urethral trauma. Urethral injuries may occur in patients with multisystem injuries and pelvic factures, as well as straddle impacts. If this is suspected, one must perform a genital and rectal exam first. If one finds blood at the meatus of the urethra, a scrotal hematoma, a pelvic fracture, or a high riding prostate then a high suspicion of urethral tear is present.
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 Up to 25% of hospitalized patients

urinary catheterization 5% per day !

Epidemiology of urinary catheterization

Catheter associated nosocomial UTI

Nosocomial UTI
40% of nosocomial infection

Bacteria ascend intraluminally into the bladder

within 24 to 72 hours (from Harrisons 16th)

> 1 month of catheterization

Nearly all will be bacteriuic

Long-term (>30 days) and short-term (<30 days) catheterization 80% of patients with nosocomial UTI
have an indwelling urinary catheter
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Women in labour Need Catheterization

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Reminder for Appropriate Urinary Catheter Use

Avoid urinary catheter use if not indicated Try to discontinue the catheter promptly when not needed
The longer the catheter is present, the higher the risk of infection! The urinary drainage system should always remain a closed system
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Rapid draining leads to Complications

Rapid drainage of large volumes of urine from the bladder may result in hypotension and/or haemorrhage.(Upson 1995) Clamp catheter if the volume drained is 1000mls or greater. After 20minutes release the clamp and allow urine to drain
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Repeat the Clamping when volume is higher

If the amount of urine is 1000mls or greater repeat the clamping procedure.
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PROCEDURE FOR EMPTYING CATHETER BAGS

Use a clean jug large enough to avoid spillage eg 2-3 litres. After emptying the bag, wipe the end of the catheter outlet with an alcohol swab. Note the amount and colour of drainage record . Empty jug carefully down the sluice to avoid splashing Place jug straight into sanitizer and store dry
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Constant evaluation to continue to use catheter .

Both nurses and physicians should evaluate the indications for urinary catheter utilization. Physicians should promptly discontinue catheters that are no longer needed. Nurses evaluating catheters and finding no indication should contact physician to promptly discontinue catheter.
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Important question when to remove

Should we need to remove the urinary catheter in 48~72 hours of smoothly post op patients to reduce the rate of catheter associated UTI? Whats the rate of catheter associated UTI in 48~ 72 hours? Remove urinary catheter as soon as possible! Rate of Bacteriuria in indwelling catheter patient in 48 hours post-OP: average 24%
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Mannequins Recruited To Teach Medicine

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Clean and Washed Hands Saves many Lives from Complications of Catheterization

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For More Articles of Interest on Infectious Diseases Visit Me

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 Programme Created by Dr.T.V.Rao MD for Medical Professionals Under the Human Safety in Medical Care
Email doctortvrao@gmail.com

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